Clepper Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Sharon, Pennsylvania.
- Location
- 959 East State Street, Sharon, Pennsylvania 16146
- CMS Provider Number
- 396071
- Inspections on file
- 28
- Latest survey
- April 8, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Clepper Manor during CMS and state inspections, most recent first.
The facility did not comply with building rehabilitation standards, as several projects were completed without submitting plans or obtaining occupancy approval. An outside generator was installed, a fire alarm panel was replaced, and the fire detection system and sprinkler head were removed from the elevator pit without proper documentation. The maintenance director confirmed the lack of required plans during the survey.
The facility was found non-compliant with building construction type requirements. A fire door failed to latch between components, and documentation proving the flame retardancy of a discharge exit canopy was missing. The maintenance director confirmed these issues during the survey.
The facility failed to maintain sprinkler system requirements as the hydraulic elevator pit lacked a sidewall sprinkler installed within two feet of the floor. This deficiency was confirmed by the maintenance director.
The facility did not meet alcohol-based hand rub dispenser requirements in a smoke compartment. An observation revealed that the basement electric control room had over 10 gallons of hand rub stored outside a cabinet and near an ignition source, with about 40 containers of 40 ounces each. The maintenance director confirmed this deficiency.
The facility was found to have deficiencies in portable fire extinguisher compliance. A fire extinguisher in the basement washing room was blocked by a janitor cart, and another in the basement elevator control room was outdated, with a last inspection date of November 2023. These issues were confirmed by the maintenance director.
The facility failed to maintain electrical system requirements as a desk was found blocking access to electric panels in the basement control room. This deficiency was confirmed by the maintenance director, indicating non-compliance with NFPA 70-110.26(a).
The facility did not meet emergency preparedness guidelines, as the last review of their emergency preparedness plan was in 2019. An interview with the maintenance director confirmed the absence of documentation for an updated review, indicating non-compliance with the required annual updates.
The facility did not meet emergency preparedness guidelines due to the absence of a documented risk assessment utilizing an all-hazards approach. This deficiency was confirmed during a document review and an interview with the maintenance director, highlighting non-compliance with the requirement to maintain an updated emergency preparedness plan.
The facility was found deficient for not providing accurate, portable floor plans during a survey. The maintenance director confirmed the inaccuracy, and observations revealed missing doors and smoke detection in certain areas. The facility also lacked accurate rating information for dining room doors. The Life Safety Code Floor Plan must include specific safety features, which were absent.
The facility did not meet fire alarm system maintenance requirements due to a communication error on the fire alarm panel. An observation revealed a trouble signal, and the maintenance director confirmed the issue.
The facility did not comply with sprinkler system maintenance standards when a minion figure was found taped to a sprinkler line in the basement electric control room. This was confirmed by the maintenance director during a survey.
A resident with a urinary catheter was observed with the drainage bag and tubing lying uncovered on the floor, contrary to infection control protocols. The LPN and Nursing Home Administrator confirmed that the catheter should not be in contact with the floor and should be covered.
Clepper Manor failed to provide written notice of the bed-hold policy to residents or their representatives when transferred to a hospital. Four residents were transferred for various medical conditions, but their records lacked evidence of the required notice. This was confirmed by an Administrative Nurse.
The facility did not ensure the Medical Director completed the required annual CME hours. There was no evidence available to confirm the completion of at least four hours of CME pertinent to medical direction or post-acute and LTC medicine. The Nursing Home Administrator could not provide documentation to verify this requirement was met.
A facility failed to document a clinical rationale for extending the use of a PRN anti-anxiety medication beyond 14 days for a resident with multiple diagnoses, including anxiety. The facility's policy requires such documentation, but the resident's record lacked evidence of the physician's rationale for the extended use of Trazadone. The DON confirmed the absence of an ordered duration for the extended PRN use.
Facility Non-Compliance with Building Rehabilitation Standards
Penalty
Summary
The facility failed to comply with building rehabilitation requirements as evidenced by several projects completed without submitting plans to the State Plan Review or obtaining a granted occupancy from the Division of Safety Inspection. On April 8, 2025, during an observation between 8:45 a.m. and 11:00 a.m., it was noted that an outside generator was installed in November 2023 without the necessary plans or an H number. Additionally, the fire alarm panel was replaced, and the automatic fire detection system and sprinkler head were removed from the elevator pit. An interview with the maintenance director on the same day confirmed that the facility was unable to provide the required plans documentation at the time of the survey. These actions indicate a failure to adhere to the NFPA 101 Building Rehabilitation standards, specifically regarding repair, renovation, modification, or reconstruction requirements, as well as the necessary compliance for changes in use or occupancy and additions.
Plan Of Correction
Maintenance director and administrator will obtain the appropriate plans and H number for the outside generator installation from the contractor and submit to the state by 5/13/2025. Maintenance director and administrator will obtain plans for the fire alarm panel that was replaced from the contractor and submit to the state by 5/13/2025. Maintenance director and administrator will obtain the appropriate plans and H number for the outside generator installation from the contractor and submit to the state by 5/13/2025. Maintenance director and administrator will obtain plans for the fire alarm panel that was replaced from the contractor and submit to the state by 5/13/2025.
Non-Compliance with Building Construction Type Requirements
Penalty
Summary
The facility was found to be non-compliant with building construction type requirements during a survey conducted on April 8, 2025. The first deficiency was observed when the fire door separating component 01 from component 02, located next to the resident entertainment room, failed to positively close or latch when released. This issue was confirmed during an interview with the maintenance director, who acknowledged the door's failure to latch at the time of inspection. Additionally, a document review revealed that the facility lacked documentation proving that the discharge exit canopy near room 112 was flame retardant. The canopy, which extends over four feet from the building and is attached to it, does not have sprinkler coverage, necessitating it to be inherently flame retardant. The maintenance director confirmed the absence of flame retardant documentation during the survey.
Plan Of Correction
Maintenance Director has replaced the latch on the fire door separating component 01 from component 02, located next to the resident entertainment room on 4/12/2025. The door now properly latches when released. The Maintenance Director will audit twice a week, Monday through Friday - ongoing. The results of the audit will be reviewed in the quality assurance committee monthly to determine if a quality assurance plan is required.
Sprinkler System Deficiency in Elevator Pit
Penalty
Summary
The facility failed to maintain sprinkler system requirements as evidenced by the absence of a sidewall sprinkler in the hydraulic elevator pit. During an observation conducted on April 8, 2025, at 12:00 p.m., it was noted that the elevator pit did not have a sidewall sprinkler installed within two feet of the floor, which is a requirement for proper sprinkler system installation. This deficiency was confirmed through an interview with the maintenance director at the same time, who acknowledged the lack of a sidewall sprinkler in the elevator pit.
Plan Of Correction
Maintenance Director to contact Mike at the department of labor elevator division and Tony from Schindler Elevator to determine/obtain documentation of the requirement needed for the elevator sprinkler.
Non-compliance with ABHR Storage Requirements
Penalty
Summary
The facility failed to comply with alcohol-based hand rub dispenser requirements in one of its smoke compartments. During an observation on April 8, 2025, it was found that the basement electric control room contained over 10 gallons of alcohol-based hand rub stored outside of a storage cabinet. This storage was located within feet of an ignition source, which is against the stipulated guidelines. The observation revealed approximately 40 containers, each holding 40 ounces of the hand rub. The maintenance director confirmed the presence of this deficiency during an interview conducted at the same time.
Plan Of Correction
Regional Maintenance Director educated administrator on the regulation pertaining to storage of alcohol based hand rub. Administrator will educate housekeeping director and housekeeping staff of the regulation. Education will be completed by 4/30/2025. Excess hand rub was removed from electric control room on 4/8/2025. There now is less than 10 gallons stored in the control room in storage cabinet.
Deficiencies in Portable Fire Extinguisher Compliance
Penalty
Summary
The facility failed to comply with the requirements for portable fire extinguishers as outlined in NFPA 10. During an observation on April 8, 2025, two deficiencies were identified. Firstly, a portable fire extinguisher in the basement washing room was obstructed by a janitor cart, preventing easy access in case of an emergency. Secondly, the portable fire extinguisher located in the basement elevator control room was found to be outdated, with a last inspection date of November 2023. These deficiencies were confirmed during an interview with the maintenance director at the time of the survey.
Plan Of Correction
Housekeeping Director immediately removed the janitor cart away from the portable fire extinguisher in the basement washing room. Regional director of maintenance educated administrator on the portable fire extinguishers on 4/14/2025. Administrator will educate housekeeping director and all housekeeping staff of the regulation pertaining to the portable fire extinguishers. Education will be completed by 5/13/2025. Administrator/designee will audit weekly for four weeks to ensure that fire extinguisher regulation is followed.
Obstructed Access to Electric Panels in Basement Control Room
Penalty
Summary
The facility failed to maintain electrical system requirements in one of over three smoke compartments. During an observation on April 8, 2025, at 10:55 a.m., it was noted that the basement electric control room had a desk obstructing access to the electric panels. This deficiency was confirmed through an interview with the maintenance director at the same time, indicating non-compliance with NFPA 70-110.26(a).
Plan Of Correction
Housekeeping director immediately moved the desk that was blocking the electric panel when surveyor observed. Regional director of maintenance educated the administrator and maintenance director on the electrical system requirements on 4/14/2025. Administrator will educate housekeeping director and all housekeeping staff. Education will be completed by 5/14/2025. Administrator/designee will audit for compliance weekly for 4 weeks to ensure compliance.
Failure to Update Emergency Preparedness Plan
Penalty
Summary
The facility failed to comply with emergency preparedness guidelines as required by federal regulations. During a document review on April 8, 2025, it was discovered that the last annual review of the facility's emergency preparedness plan was conducted on January 17, 2019. This indicates that the facility did not perform the required annual review and update of the emergency preparedness plan for several years, which is a clear violation of the regulatory requirements. An interview with the maintenance director on the same day confirmed that the facility was unable to provide documentation of an updated annual review date at the time of the survey. This lack of documentation further substantiates the facility's failure to maintain compliance with the emergency preparedness guidelines, as they could not demonstrate that the plan had been reviewed and updated as mandated.
Plan Of Correction
1. Administrator and Maintenance Director conducting review and updates for emergency preparedness plan. 2. Emergency preparedness plan will be updated by 5/12/2025. 3. Administrator and Maintenance Director will provide all staff education on emergency preparedness plan. 4. All staff education will be completed by 5/14/2025.
Failure to Document All-Hazards Risk Assessment
Penalty
Summary
The facility failed to meet emergency preparedness guidelines as required by regulations. During a document review on April 8, 2025, it was found that the facility did not have a documented risk assessment that utilized an all-hazards approach. This is a critical component of the emergency preparedness plan that should be reviewed and updated at least annually for long-term care facilities. An interview with the maintenance director on the same day confirmed the absence of the necessary documentation. The lack of a documented risk assessment indicates that the facility did not comply with the requirement to develop and maintain an emergency preparedness plan based on a facility-based and community-based risk assessment, which is essential for addressing potential emergency events.
Plan Of Correction
Risk assessment was completed for the facility in our company's electronic system. The facility printed the assessment and has placed it in our life safety binder. The maintenance director and administrator will ensure that when the risk assessment is completed, it is printed and placed in the life safety binder at the time of completion.
Inaccurate Life Safety Code Floor Plans and Missing Safety Features
Penalty
Summary
The facility was found to be deficient in providing an accurate and portable set of floor plans during a document review conducted on April 8, 2025. The Division of Safety Inspection mandates that all facilities under its jurisdiction maintain such floor plans on-site for use during Life Safety Code Surveys. The review revealed that the facility's floor plans were not accurate, as confirmed by the maintenance director. This deficiency was noted during an interview with the maintenance director, who acknowledged the inaccuracy of the Life Safety Code Floor Plan at the time of the survey. Additionally, an observation conducted on the same day revealed multiple areas within the facility that lacked doors and smoke detection systems leading to the corridor. Furthermore, the facility was unable to provide accurate rating information for the dining room doors leading to the entertainment area. The Life Safety Code Floor Plan is required to include specific details such as smoke barrier walls, fire barrier walls, horizontal exits, rated rooms, required exits, shaft walls, and a door schedule. The absence of these elements in the facility's floor plan contributed to the deficiency noted in the survey.
Plan Of Correction
Maintenance Director and Administrator will update the floor plan with clear description of: a. smoke barrier walls (outside wall to outside wall) b. fire barrier walls (1-2 hour walls) c. horizontal exits d. rated rooms (storage rooms, soiled utility rooms, designated medical gas rooms) e. exits noted f. shaft walls g. door schedule This will be completed by 5/13/2025. Maintenance Director and Administrator will update the portable floor plan to keep in life safety manual to include: a. smoke barrier walls (outside wall to outside wall) b. fire barrier walls (1-2 hour walls) c. horizontal exits d. rated rooms (storage rooms, soiled utility rooms, designated medical gas rooms) and they will be clearly designated e. required exits clearly noted f. shaft walls g. door schedule This will be completed by 5/14/2025.
Fire Alarm System Maintenance Deficiency
Penalty
Summary
The facility failed to meet the fire alarm system maintenance and testing requirements as evidenced by a communication error on the fire alarm panel. During an observation on April 8, 2025, at 10:45 a.m., a trouble signal was noted on the fire alarm panel indicating a communication error. This issue was confirmed through an interview with the maintenance director at the same time, who acknowledged the presence of the communication error.
Plan Of Correction
Maintenance director contacted Summit Fire regarding the trouble signal listed for communication error. Summit came out on 4/29/2025, reset the panel, and the issue was temporarily corrected. Summit ordered the part needed to repair completely, and it is scheduled to be in and repaired at the latest 5/12/2025. Maintenance director contacted Summit Fire to come out and correct the fire panel communication error. Summit came out and ordered a new part to fix the issue on April 31, 2025. Once the part arrives, Summit will be out to replace the part.
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to meet the sprinkler system maintenance and testing requirements as evidenced by an observation in the basement electric control room. During the survey conducted on April 8, 2025, at 10:30 a.m., it was observed that a fictional character figure, specifically a minion, was taped to the sprinkler line. This deficiency was confirmed through an interview with the maintenance director at the same time, indicating a lapse in adhering to the standards set by NFPA 25 for the inspection, testing, and maintenance of water-based fire protection systems.
Plan Of Correction
Fictional character was removed immediately when noted by life safety surveyor. Regional maintenance director educated administrator on regulation on sprinkler system maintenance and testing requirements on 4/15/2025. Administrator will educate housekeeping director and all housekeeping staff on sprinkler system maintenance and testing requirements by 5/14/2025. Maintenance director/designee will round weekly for the next four weeks to ensure compliance. Results of audit will be reviewed with administrator weekly.
Infection Control Lapse with Urinary Catheter
Penalty
Summary
The facility failed to adhere to acceptable infection control practices concerning the care and treatment of a resident with a urinary drainage catheter. During an observation, it was noted that the catheter drainage bag and tubing of a resident were lying on the floor without any covering. This was confirmed by a Licensed Practical Nurse (LPN) who acknowledged that the drainage bag and tubing should not be in contact with the floor or any unclean surface. The resident involved had an admission date of March 17, 2025, and was diagnosed with osteolysis, chronic obstructive pulmonary disease (COPD), and a urinary tract infection. The Nursing Home Administrator also confirmed that catheter bags should not be placed on the floor and should be covered, indicating a lapse in following the facility's infection control protocols.
Plan Of Correction
No residents were negatively impacted. When notified by the surveyor, the Director of Nursing provided a privacy bag to the resident with a Foley catheter and ensured it was off the floor. The Director of Nursing observed all other residents with Foley catheters to ensure they had privacy in place and that it was not touching the floor. The Regional Director of Clinical Operations educated the Administrator and Director of Nursing on the Catheter Care Policy and infection control policy on 4.15.25. The Director of Nursing/designee will educate all direct care staff on the Catheter Care policy and infection control policy beginning on 4.15.25. All education will be completed by 5.1.25. The Director of Nursing/designee will audit all residents with Foley catheters three times per week for four weeks to ensure that proper policy and infection control measures are being followed. Audits will begin on 5.1.25. Results of the audit will be reviewed by the QA committee to determine further need.
Failure to Provide Bed-Hold Policy Notice
Penalty
Summary
Clepper Manor was found to be non-compliant with the requirements of 42 CFR Part 483, Subpart B, specifically regarding the notice of bed-hold policy before and upon transfer of residents. The facility failed to provide written notice of the bed-hold policy to residents or their representatives when residents were transferred to a hospital. This deficiency was identified through a review of clinical records and staff interviews, which revealed that four residents, identified as R5, R8, R15, and R40, did not receive the required written notice of the bed-hold policy upon their transfer to a hospital. The clinical records of these residents showed that they were transferred to an acute care hospital for various medical conditions, including a urinary tract infection, a cardiac event, acute respiratory failure, and a fractured left leg. Despite these transfers, there was no evidence in the clinical records that the residents or their representatives were provided with the necessary written information about the duration and cost of the bed-hold policy. This was confirmed during an interview with the Administrative Nurse, who acknowledged that the bed-hold policy was not provided as required.
Plan Of Correction
No residents negatively impacted. Director of Nursing and Social Service designee did identify residents during the time of survey that were sent out to the hospital that did not receive bed hold notices. Social Service designee was able to correct by providing the notices to those residents. Regional Director of Clinical Operations educated Administrator, Social Service Designee, and Director of Nursing on bedhold letter, policy, and process on 4.15.25. Administrator / designee will educate all nurses on bedhold letter, policy, and process beginning 4.15.25. All education will be completed by 5.1.25. Administrator / designee will audit all resident transfers for 4 weeks to ensure notices are sent with resident (POA if applicable), at the time of transfer or within 24 hours, per regulation and the policy was followed. Audits will begin 4.15.25. Results of audit will be reviewed by QA committee to determine further need.
Medical Director CME Requirement Not Met
Penalty
Summary
The facility failed to ensure that the Medical Director completed the required annual continuing medical education (CME) hours. According to the regulation, the Medical Director must complete at least four hours annually of CME pertinent to the field of medical direction or post-acute and long-term care medicine. However, upon review of facility documentation and through staff interviews, it was determined that there was no available evidence to confirm the completion of these CME hours. During an interview, the Nursing Home Administrator was unable to provide documented evidence that the Medical Director had fulfilled this requirement.
Plan Of Correction
Medical Director was out of the country at the time of survey. Administrator to follow up with Medical Director upon return and obtain certificate of completion. Medical Director returned from vacation week of 4/14/2025. Facility did reach out and obtained documentation of completed continuing education, which was forwarded to the field office. Administrator/designee will review in quarterly quality assurance committee meeting to ensure we have up-to-date documentation on hand.
Failure to Document Clinical Rationale for Extended PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a PRN anti-anxiety psychotropic medication had a clinical rationale identified for use beyond the 14-day limitation for a resident. The facility's policy on the use of psychotropic medication requires that PRN orders for such drugs be used only when necessary to treat a diagnosed specific condition documented in the clinical record and for a limited duration of 14 days. If an extension is needed, the attending physician must document the rationale and indicate the duration in the resident's medical record. In this case, a resident with diagnoses including palliative care, severe protein-calorie malnutrition, chronic obstructive pulmonary disease, and anxiety was prescribed Trazadone 100 mg by mouth at hour of sleep PRN. However, the clinical record lacked evidence of a clinical rationale for the use of Trazadone beyond 14 days. During an interview, the Director of Nursing confirmed that there was no duration ordered by the physician for the extended use of the PRN Trazadone beyond the 14-day period.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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